The Public's Perception on Breast and Nipple Reconstruction

Aesthetic Surgery Journal2019, Vol 39(9) NP370–NP376© Published by Oxford University Press on behalf of The American Society for Aesthetic Plastic Surgery 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.DOI: 10.1093/asj/sjy281www.aestheticsurgeryjournal.com

Original ArticleBreast Surgery

The Public’s Perception on Breast and Nipple Reconstruction: A Crowdsourcing-Based Assessment

Beina Azadgoli, MD; Daniel J. Gould, MD, PhD; Emma Vartanian, MD; and Ketan M. Patel, MD

AbstractBackground: Breast reconstruction outcomes have traditionally been measured by evaluating the opinions of patients and surgeons.Objectives: Our goal was to assess the views of the general public.Methods: A survey was designed and distributed through a crowdsourcing website called Amazon Mechanical Turk. Questions assessed participant demographics, personal experience with breast reconstruction, perceptions on breast reconstruction, and opinions regarding aesthetics results. Responses were analyzed using chi-square test.Results: A total of 992 responses were collected. Most participants were female (56.1%), white (32.1%), aged 30 to 39 years (40.4%), and had a bachelor’s degree (42.0%). A total of 44.2% had personal experience with breast reconstruction and 25.8% with nipple reconstruction. Several aes-thetic and reconstructive factors were significantly favored over others across sex, ethnicity, age group, education level, and personal experience with breast reconstruction. For instance, women were more likely to prefer reconstructed nipples (P < 0.0001), view a breast without a nipple as complete (P = 0.024) and place less importance on nipple shape (P = 0.002). Additionally, those who personally experienced nipple reconstruction were willing to undergo more procedures for a complete nipple-areola complex (P < 0.0001), to increase aesthetic results (P = 0.018), and to increase chances of nipple survival (P = 0.002).Conclusions: Crowdsourcing can be useful in plastic surgery and has helped identify several key findings. The importance of the nipple in recon-struction has been validated; almost three-quarters of respondents did not view a breast without a nipple as complete. The aesthetic preferences seem to support bilateral nipple-sparing reconstruction when possible. Most importantly, the respondents helped elucidate key differences in perception of aesthetic outcomes.

Editorial Decision date: October 10, 2018; online publish-ahead-of-print October 17, 2018.

Nipple areola complex (NAC) reconstruction is a fun-damental part of the breast reconstruction process for patients who underwent mastectomy after breast cancer. Not only does it symbolize the end of treatment for these patients, but it also leads to a significant improvement in overall patient contentment as well as satisfaction with nude appearance.1

Although nipple-sparing mastectomy (NSM) is the pre-ferred technique due to improved cosmetic results, greater sensitivity, and decreased feelings of mutilation,2 it is not always a feasible option for patients from an oncologic standpoint. After skin sparing mastectomy, a combination

of local tissue rearrangement using a variety of local flaps can be employed to create a nipple, and this can be improved through tattooing of the surrounding skin.3,4 Alternatively, excellent 3-dimensional (3D) tattooing

From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.

Corresponding Author: Dr Ketan M. Patel, Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Suite 415, Los Angeles, CA 90033, USA. E-mail: [email protected]

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options exist for patients who want to avoid further nipple surgery. Despite these available options, there are often cases in which patients prefer to avoid nipple reconstruc-tion altogether.5

Traditionally, outcomes following breast reconstruc-tion have been measured by assessing opinions of the patients who underwent the procedure and the physicians who performed them, both of whom are innately biased. Although there are several studies describing patient sat-isfaction after NSM as well patient views on breast re-construction,3,5-12 to our knowledge, there are no reports describing the opinion of the more generalized population.

Therefore, we designed a survey that we distributed through a crowdsourcing website operated by Amazon called Mechanical Turk, which is an internet service that provides a large, diverse, human workforce to provide rapid feedback in large numbers. Although this crowd-sourcing tool has been previously validated in the plastic surgery literature by Wu and colleagues, who used it to characterize the most important attributes of aesthetic sur-geons,13 as well as Vartanian et al, who used it to assess the public’s perception of attractive thighs,14 we chose to apply the tool to better understand views on breast and nipple reconstruction.

Our goal was to highlight the general population’s over-all perception on breast and nipple reconstruction, under-stand public opinion on aesthetic outcomes following nipple reconstruction employing a variety of surgical tech-niques, and to further illustrate the potential of Mechanical Turk as a medium to understand public preferences and guide reconstructive surgery decision-making.

METHODS

After obtaining approval from the Institutional Review Board of the University of Southern California, the authors developed a study survey containing questions assessing participant demographics, general perception on breast re-construction, personal experience with breast reconstruc-tion, and opinions on the aesthetics of breast and nipple reconstruction.

Questions were designed in yes or no format, multi-ple choice, and ranking in order of importance. Ranking questions employed the following scale: not important at all, not very important, neutral, important, and extremely important.

In questions evaluating opinions on breast aesthetics, participants were asked to choose between images display-ing different reconstructive techniques. Participants were instructed to compare between breasts that had undergone NSM vs NAC reconstruction, NAC reconstruction vs 3D nipple tattooing without nipple reconstruction, and uni-lateral vs bilateral reconstruction. Images were obtained from the operative photos of surgical patients who signed

an informed consent allowing photographs to be used for research purposes.

Surveys were distributed electronically through the crowdsourcing platform, Amazon Mechanical Turk, in which anonymous users were offered $0.05 for their responses from May to July 2017. The survey was not limited to any specific geographical location and MTurkers were not required to be “expert” evaluators. A sample of the survey is provided in Appendix A (available online as Supplementary Material at www.aestheticsurgeryjournal.com).

Study data were collected and managed using REDCap electronic data capture tools hosted at the University of Southern California. Statistical analysis of the data was performed using Microsoft Excel 2016 (Microsoft Corp., Redmond, WA). Statistical significance was defined as P < 0.05.

RESULTS

A total of 992 responses were completed. Of these, 438 (44.2%) responders were male and 554 (55.8%) were fe-male (Figure 1); 556 (56.1%) of the respondents classified themselves as white, 319 (32.1%) Asian, 52 (5.2%) black, 37 (3.7%) Hispanic, and 29 (2.9%) as other (Figure 2). Respondents were sorted into the following age groups: 18 to 29, 30 to 39, 40 to 49, 50 to 59, and 60+ years old; the average age was 33.2 years. The most represented ages were the 30- to 39-year-old (40.42%) and 18- to 29-year-old groups (37.7%). However, 12.8% of our respondents were 40 to 49, 6.3% were 50 to 59, and 2.8% were older than 60 years (Figure 3). The education level of our respond-ents ranged from less than a high school degree (0.6%) to a graduate degree (19.8%); most of our population com-pleted an undergraduate education (42.0%) (Figure 4).

Personal Experience with Breast Reconstruction

A total of 438 (44.2%) of our respondents either under-went breast reconstruction or knew someone who had, 256 (25.8%) underwent nipple reconstruction or knew someone who had, and 324 (32.7%) had personally seen reconstructed nipples.

Breast Preferences Overall

Most of our population (84.3%) preferred the image of NSM to reconstructed nipples (15.6%). Similarly, more respondents preferred tattooed nipples (57.5%) to recon-structed nipples (42.5%). While 51.1% preferred the image of bilateral breast reconstruction, 48.9% preferred unilateral reconstruction.

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Differences in Preference Across Demographics

NSM vs Nipple Reconstruction Between men and women, both preferred the image of NSM to nipple reconstruction. However, whereas 19.9% of women preferred nipple reconstruction, only 10.2% of men chose nipple reconstruction (P < 0.0001) (Table 1). Across the various ethnic groups, a total of only 15.6% preferred the image of the reconstructed nipple to NSM; however, preference for nipple reconstruction ranged from 11% in Hispanics to 31% in Blacks (P = 0.013) (Table 2). The preference for NSM over nipple reconstruction was universal across age (P = 0.708) (Table 3) and education groups (P = 0.492) (Table 4).

Nipple Reconstruction vs Tattoo Regarding nipple reconstruction compared with tattooed nipples, significantly more men preferred tattooed nipples

compared with women (P = 0.03) (Table 1). Among the different age groups, those aged 40 to 49 years had a stronger preference for tattooed nipples, and those aged 60+ years preferred reconstructed nipples (P = 0.01) (Table 3). However, there was no significant difference in preference across ethnicity (P = 0.206) (Table 2) or educa-tion level (P = 0.749) (Table 4).

Unilateral vs Bilateral Breast Reconstruction When comparing unilateral and bilateral breast recon-struction, there was no significant difference between preferences for either across sex (P = 0.523) (Table 1) or education level (0.685) (Table 4). However, between the various ethnic groups, Hispanics and those who clas-sified themselves as “other” had a stronger preference for bilateral breast reconstruction (62.2% and 62.1%, respectively) (P < 0.005) (Table 2). On the other hand, among the different age groups, those aged 40 to 49 and 50 to 59 years had a stronger preference for unilateral

60Sex

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Figure 1. The demographics of our survey population by sex.

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Figure 2. The demographics of our survey population by ethnicity.

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18-29 30-39 40-49 50-59 60+

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% 20151050

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Figure 3. The demographics of our survey population by age group.

504030

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ollege AA

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Figure 4. The demographics of our survey population by education level. AA, associate degree; GED, general education diploma.

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breast reconstruction (59.8% and 62.3%, respectively) (P = 0.007) (Table 3).

Overall Perceptions on Breast ReconstructionA total of 704 (71.0%) of our population felt that a breast without a nipple is incomplete. To achieve a complete NAC, most respondents (39.5%) would be willing to undergo a maximum of 2 additional procedures (after mastectomy), 29.8% would undergo 1, 14.2% would undergo 3, 8.4% would undergo 4, and 8.1% would not undergo any add-itional surgeries. For a majority of our respondents (32.7%), no imperfection in results would prevent them from receiv-ing nipple reconstruction. However, the most common deterring factor was asymmetric results (30.7%) followed by imperfect nipple shape (14.2%), lack of nipple projec-tion (12.3%), and finally, imperfect areolar shape (10.2%).

Age was an important factor in choosing to undergo fur-ther surgery. Most of our population would not be willing to undergo additional surgery for NAC reconstruction after age 55 years (29.8%) or age 45 years (27.4%). However, a small percentage would choose to undergo surgery until age 75 years (9.2%). Most of our population would be willing to receive an increased number of procedures to improve the chance of nipple survival (69.4%) and to improve the aesthetic results (65.0%). However, most would not choose to receive nipple reconstruction if they knew the nipple pro-jection would decrease significantly in the future (51.3%).

DISCUSSION

This study aimed to evaluate the general population’s per-ceptions and opinions on breast reconstruction. Whereas many authors have described their patients’ attitudes about their own surgery,3,5-12 the views of the overall

public have traditionally been neglected. By surveying a wide range of individuals using an anonymous internet survey distributed through Amazon Mechanical Turk, we sought to better understand people’s insight into breast re-construction and establish population-based guidelines for more specific patient-directed surgical planning.

Overall, our study revealed that the public’s thoughts on breast and nipple reconstruction are generally aligned with those of patients. For instance, patient studies have shown that NAC presence significantly influences aes-thetic satisfaction after breast reconstruction.15 In a study conducted by Yueh et al, all women who underwent NSM stated that they were willing to accept an increased risk of local cancer recurrence to preserve their nipple and areola. Whereas 80% of these women stated that NAC preserva-tion provided a sense of wholeness, 30% felt that the aes-thetic component of NAC preservation played a significant role in their decision.16 Similarly, more than 70% of our respondents viewed a breast without a nipple as incom-plete, and many respondents were willing to receive sev-eral procedures and tolerate imperfect results for the sake of a complete breast.

Regarding nipple tattooing, a survey of 40 women showed that nearly 90% of patients were satisfied with their results and felt that the tattooing improved their body image overall, whereas women who underwent NAC reconstruction considered that to be the most unsatisfac-tory part of their reconstruction and were often less sat-isfied than their surgeons with the results.17 Comparably, more of our respondents preferred tattooed nipples over reconstructed ones.

Several additional key concepts were brought to light by this study. First, a large proportion of the general public has been exposed to breast reconstructive surgery. Given the relatively high population frequency of breast cancer and increasing indications and procedures for mastectomy, it is understandable why this may be so. According to the American Society of Plastic Surgeons, breast reconstruc-tion accounted for approximately 2% of all reconstructive procedures in 2016, which is a 40% increase since the year 2000.18 Given these high exposure rates, the public’s notions on breast reconstruction are proving to be increas-ingly relevant. With increasing coverage in social media and other interactive platforms, the general public is becoming more aware of breast and nipple reconstruction, and the onus is on reconstructive surgeons to provide the highest quality aesthetic outcomes. The data provided by this study can be used by surgeons while educating their patients during preoperative discussions.

A second finding of this study is that many individu-als are willing to receive several surgeries, on average 2 after mastectomy, to achieve the best aesthetic results. In a time of increasing insurance scrutiny and during the rise of diagnostic-related grouping-based reimbursement,

Table 1. Image Preferences of Our Population Divided by Sex

Preferences by sex

NSM Nipple reconstruction

Men 393 (89.7%) 45 (10.3%)

Women 444 (80.1%) 110 (15.6%)

Nipple reconstruction Tattoo

Men 169 (38.6%) 269 (61.4%)

Women 253 (45.7%) 301 (54.3%)

Unilateral Bilateral

Men 209 (48.4%) 229 (52.3%)

Women 276 (48.9%) 278 (51.%)

NSM, nipple-sparing mastectomy.

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studies like this will allow surgeons to have some lev-erage in the debate regarding the number and types of surgeries that should be covered in breast reconstruction. Undeniably, all women should have access to breast re-construction, and plastic surgery should advocate for more financial coverage of such procedures. These data can be used to support the concept that ideal recon-struction involves several surgeries in addition to nipple reconstruction.

Our third main finding is that patients may have an age cutoff, and as they age, they are less likely to want to receieve multiple procedures for the best outcomes. Surgeons should discuss patient expectations and desires but should also strongly advocate for the best aesthetic outcomes for the patient to improve the quality of life after reconstruction.

Although this study sheds light on several interesting considerations, it also has many limitations. First, given the survey-based nature of the study, our results are based on the truthfulness of the respondents. Although each worker was required to submit a unique identification code upon completion of the survey to get reimbursed, this

does not guarantee that no one was able to take the survey more than once for another wage.

Second, the images used in our survey potentially raise some bias in our results. For instance, although we introduced a single image as an example of each of the different types of reconstruction (NSM, nipple recon-struction, and tattooed nipples), respondents may have had different preferences if we had provided additional photos demonstrating each of the various types of recon-struction. Additionally, the image of the tattooed nipple displays a 3D tattoo, which is not universally performed by everyone.

Finally, some limitation lies in the way several of our questions were phrased. By asking, “Do you or someone you know…?” the questions that assess respondents’ per-sonal experience with breast and nipple reconstruction (#26 and #27) do not specify whether it is the participant who has experience with breast/nipple reconstruction, or if their answer is referring to someone they know. This distinction could potentially have a significant effect on our results.

Despite these reservations, these data provide plastic surgeons with meaningful information about the differing

Table 2. Image Preferences of Our Population Divided by Ethnicity

Preferences by ethnicity


White 481 (86.5%) 75 (13.5%)

Black 36 (69.2%) 16 (30.8%)

Hispanic 33 (89.2%) 4 (10.8%)

Asian 264 (83.0%) 54 (17.0%)

Other 23 (79.3%) 6 (20.7%)


White 244 (43.88%) 312 (56.12%)

Black 22 (42.3%) 30 (57.7%)

Hispanic 12 (32.4%) 25 (67.6%)

Asian 127 (39.9%) 191 (60.1%)

Other 17 (58.6%) 12 (41.4%)


White 302 (54.3%) 254 (45.7%)

Black 24 (46.2%) 28 (53.9%)

Hispanic 14 (37.8%) 23 (62.2%)

Asian 134 (42.1%) 184 (58.9%)

Other 11 (37.9%) 18 (62.1%)


Table 3. Image Preferences of Our Population Divided by Age Group

Preferences by age group


18-29 320 (85.6%) 54 (14.4%)

30-39 332 (82.8%) 69 (17.2%)

40-49 107 (84.7%) 20 (15.7%)

50-59 55 (88.7%) 7 (11.3%)

60+ 23 (82.1%) 5 (17.9%)


18-29 167 (44.7%) 207 (55.4%)

30-39 163 (40.7%) 238 (59.4%)

40-49 43 (33.9%) 84 (66.1%)

50-59 30 (48.4%) 32 (51.6%)

60+ 19 (67.9%) 9 (32.1%)


18-29 163 (43.6%) 211 (56.4%)

30-39 194 (48.4%) 207 (51.6%)

40-49 76 (59.8%) 51 (40.2%)

50-59 39 (61.3%) 24 (38.7%)

60+ 14 (50.0%) 14 (50.0%)


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opinions of a wide range of demographic populations with respect to breast and nipple reconstruction, and this infor-mation can be used in practice for more patient-specific surgical care.

CONCLUSIONS

The critical finding for all breast reconstructive surgeons here is that in discussion with patients, surgeons should ad-vocate for nipple reconstruction while informing patients that it may take up to 2 additional surgeries but that most patients are willing to undergo these. Additionally, though age may affect their choice, surgeons should advocate for definitive nipple reconstruction to improve aesthetic out-comes and quality of life.

In the future, additional crowdsourcing algorithms may help better define aesthetic guidelines and outcomes to im-prove patient care.

Supplementary MaterialThis article contains supplementary material located online at www.aestheticsurgeryjournal.com.

DisclosuresThe authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

FundingThe authors received no financial support for the research, authorship, and publication of this article.

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Table 4. Image Preferences of Our Population Divided by Education Level

Differences by education level


<High school degree 5 (83.3%) 1 (16.7%)

High school/GED 72 (85.7%) 12 (14.3%)

Some college 162 (85.3%) 28 (14.7%)

AA 88 (88.9%) 11 (11.1%)

Bachelor’s 341 (81.8%) 76 (18.2%)

Graduate 169 (86.2%) 27 (13.8%)



High school/GED 30 (35.7%) 54 (64.3%)

Some college 86 (45.3%) 104 (54.7%)

AA 42 (42.4%) 57 (57.6%)

Bachelor’s 181 (43.4%) 236 (56.6%)

Graduate 80 (40.8%) 116 (59.2%)



High school/GED 40 (47.6%) 44 (52.4%)

Some college 92 (48.4%) 98 (51.6%)

AA 53 (53.5%) 46 (46.5%)

Bachelor’s 208 (49.9%) 209 (50.1%)

Graduate 88 (44.9%) 108 (55.1%)

AA, associate degree; GED, general education diploma; NSM, nipple-sparing mastectomy

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17. El-Ali K, Dalal M, Kat CC. Tattooing of the nipple-are-ola complex: review of outcome in 40 patients. J Plast Reconstr Aesthet Surg. 2006;59(10):1052-1057.

18. Liu D. New plastic surgery statistics and breast recon-struction trends. https://www.plasticsurgery.org/news/blog/new-plastic-surgery-statistics-and-breast-reconstruc-tion-trends. Published 2017. Accessed June 8, 2018.

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The Public's Perception on Breast and Nipple Reconstruction

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